Knotless soft tissue devices and techniques

ABSTRACT

A tissue fixation device including a self-locking construct having a first loop, a second loop, and a first free end. A first tail is coupled to, and extends from, the first loop. A second tail is coupled to, and extends from, the second loop. An anchor is coupled to one of the self-locking construct or the first tail such that one of the self-locking construct or the first tail extend through the anchor.

FIELD

The present disclosure relates to knotless soft tissue devices andtechniques.

BACKGROUND

This section provides background information related to the presentdisclosure, which is not necessarily prior art.

Arthroscopic procedures often include sutures and anchors to secure softtissue to bone, secure bone pieces together, and to secure separatedportions of soft tissue together. Despite their widespread use, suturesand suture anchors, as well as methods for their use, can be improved.For example, tying sutures into knots may be very time consuming anddifficult to perform, particularly inside the joint space. As a result,the cost of the procedure may increase and the capacity of the surgeonmay be limited. Furthermore, the strength of the repair may be limitedby the strength of the knot. The methods and devices disclosed hereinaddress these issues and numerous others.

SUMMARY

This section provides a general summary of the disclosure, and is not acomprehensive disclosure of its full scope or all of its features.

The present teachings provide for a tissue fixation device including aself-locking construct having a first loop, a second loop, and a firstfree end. A first tail is coupled to, and extends from, the first loop.A second tail is coupled to, and extends from, the second loop. Ananchor is coupled to one of the self-locking construct or the first tailsuch that one of the self-locking construct or the first tail extendthrough the anchor.

The present teachings also provide for a tissue fixation deviceincluding a self-locking construct having a first loop and a free end. Afirst tail is coupled to, and extends from, the first loop. A secondtail is coupled to, and extending from, the self-locking construct. Ananchor is coupled to the first tail such that the self-locking constructextends through the anchor.

The present teachings also provide for a method for securing soft tissueto bone. The method includes implanting a first anchor into bone, thefirst anchor coupled to one of a first loop of a first self-lockingconstruct or a first tail mounted to the first loop. The first tail anda portion of the first loop are passed through the tissue. The firsttail is passed through a second loop and the first loop is partiallypassed through the second loop on a side of the tissue opposite to thebone. A first free end of the first self-locking construct is pulled toclose the first loop.

Further areas of applicability will become apparent from the descriptionprovided herein. The description and specific examples in this summaryare intended for purposes of illustration only and are not intended tolimit the scope of the present disclosure.

DRAWINGS

The drawings described herein are for illustrative purposes only ofselected embodiments and not all possible implementations, and are notintended to limit the scope of the present disclosure.

FIG. 1 illustrates a tissue fixation device according to the presentteachings;

FIG. 2 illustrates the tissue fixation device of FIG. 1 in bone;

FIG. 3 illustrates two of the tissue fixation devices of FIG. 1implanted in bone to affix tissue relative to the bone;

FIGS. 4-8 illustrate use of the tissue fixation device of FIG. 1 to fixthe tissue to bone;

FIG. 9 illustrates three of the tissue fixation devices of FIG. 1implanted in bone for affixing tissue to bone;

FIG. 10 illustrates the tissue fixation device of FIG. 1 implanted inbone, and an additional flexible anchor being added to the fixationdevice;

FIG. 11 illustrates the tissue fixation device of FIG. 1 implanted inbone to secure tissue to bone, and the additional anchor of FIG. 10implanted in bone to facilitate tissue fixation and tensioning;

FIG. 12 illustrates another tissue fixation device according to thepresent teachings, with an anchor positioned on a suture construct ofthe tissue fixation device;

FIG. 13 illustrates the tissue fixation device of FIG. 12 with theanchor positioned on a tail of the tissue fixation device;

FIGS. 14-18 illustrate use of the tissue fixation device of FIG. 13 toaffix tissue to bone;

FIG. 19 illustrates the tissue fixation device of FIG. 13 including abraided strip;

FIGS. 20 and 21 illustrate use of a braided strip to facilitate securingtissue to bone; and

FIGS. 22A-22C illustrate a tail of either one of the tissue fixationdevices of FIGS. 12 and 13 coupled to a loop of the tissue fixationdevices, and use of the tail to open the loop.

Corresponding reference numerals indicate corresponding parts throughoutthe several views of the drawings.

DETAILED DESCRIPTION

Example embodiments will now be described more fully with reference tothe accompanying drawings.

With initial reference to FIG. 1 , a tissue fixation device according tothe present teachings is generally illustrated at reference numeral 10.Although the tissue fixation device 10 is generally described herein asconfigured to secure tissue to bone, the tissue fixation device 10 canalso be used to, for example, secure two bones or bone portionstogether, as well as two tissues or tissue portions together. The tissuefixation device 10 generally includes a soft or flexible anchor 12 and aself-locking construct 14.

The anchor 12 includes a first anchor end 20 and a second anchor end 22,which is opposite to the first anchor end 20. The anchor 12 can be anelongate member having a sleeve or tubular configuration. The anchor 12thus defines a first opening 24 at the first anchor end 20, and definesa second opening 26 at the second anchor end 22. The anchor 12 furtherdefines an anchor internal passage 28 extending between the firstopening 24 and the second opening 26. At the first anchor end 20 is afirst end surface 30, and at the second anchor end 22 is a second endsurface 32. As described herein, the first and the second end surfaces30 and 32 are configured to abut an interior surface of cortical bone inorder to facilitate retention of the tissue fixation device 10 within abone hole.

In place of the anchor 10, any suitable soft or hard anchor can be used,such as any of the soft or hard anchors described in U.S. applicationSer. No. 13/098,927 (“'927 application”) titled “Method and Apparatusfor Soft Tissue Fixation,” filed on May 2, 2011, and assigned to BiometSports Medicine, LLC, which is incorporated herein by reference. Inplace of the anchor 10 can also be any of the anchors described in U.S.Pat. No. 8,562,647 ('647 patent”) titled “Method and Apparatus forSecuring Soft Tissue to Bone,” issued on Oct. 22, 2013, and assigned toBiomet Sports Medicine, LLC, which is incorporated herein by reference.The anchor 12 can be made of any suitable material, such as resorbableor non-resorbable materials, including braided suture, sponges, andsponge-like materials, including braided suture, sponges, andsponge-like materials in solid form, perforated materials, woven/braidedfrom biocompatible materials or fibers, such as, for example, polymer,polyester, polyethylene, cotton, silk, or other natural or syntheticmaterials.

The self-locking construct 14 can be made of any suitable material, suchas a flexible material including suture, such as a suture strand 50.When the construct 14 is made of suture, any suitable suture can beused. For example, a braided hollow-core suture strand 50 can be used.Any suitable braided suture can be used, such as any of the braidedsutures disclosed in U.S. patent application Ser. No. 12/915,962 titled“Method and Apparatus for Securing Soft Tissue to Bone,” which was filedon Oct. 29, 2010, published as Publication No. 2011/0098727 on Apr. 28,2011, and is assigned to Biomet Sports Medicine, LLC. Although theconstruct 14 can be made of any suitable material in addition to suture,the construct 14 will generally be described herein as a construct.

The construct 14 generally includes a first end 52 and a second end 54of the suture strand 50. The suture strand 50 is arranged to provide aself-locking, first adjustable loop 56 and a self-locking, secondadjustable loop 58. The suture strand 50 includes a portion 60 betweenthe first end 52 and the second end 54. The portion 60 itself includes afirst end 62 and a second end 64. The portion 60 defines a passageway orinternal passage portion 66 extending between the first end 62 and thesecond end 64 of the portion 60.

As illustrated in FIG. 1 , portions of the suture strand 50 extendthrough the internal passage portion 66. The suture strand 50 passesthrough the internal passage portion 66 a first time to define the firstadjustable loop 56, and a second time to define the second adjustableloop 58. The internal passage portion 66 can be any suitable passagethrough the suture strand 50, through which portions of the suturestrand 50 can pass to define the first and the second adjustable loops56 and 58, such as the passage portions described in the '927application and the '647 patent, which are incorporated herein byreference.

Slidably mounted to the first adjustable loop 56 is a first suture tail70 a. Slidably mounted to the second adjustable loop 58 is a secondsuture tail 70 b. The first suture tail 70 a is similar to the secondsuture tail 70 b. In order to facilitate differentiation between thefirst suture tail 70 a and the second suture tail 70 b, such as by asurgeon in the operating room, the first suture tail 70 a and the secondsuture tail 70 b can include any suitable distinguishing identifiers.For example, the first and second suture tails 70 a and 70 b can beprovided with different colors, different visual patterns, differentindicia (such as different striping) different sizes (such as differentlengths or widths), or different materials.

The first suture tail 70 a and the second suture tail 70 b can each bemade of any suitable material, such as the same material as the suturestrand 50, or any of the alternative materials of the suture strand 50described above. Features in common between the first and second suturetails 70 a and 70 b are illustrated and described using similarreference numbers, but reference numbers of the first suture tail 70 ainclude the suffix “a,” and reference numbers of the second suture tail70 b include the suffix “b.” Because the first suture tail 70 a issimilar to the second suture tail 70 b, the detailed description belowof the first suture tail 70 a describes the second suture tail 70 b aswell.

The first suture tail 70 a includes a first end 72 a and a second end 74a. The first end 72 a is opposite to the second end 74 a. At the firstend 72 a is a locking portion 76 a. Extending from the locking portion76 a to the second end 74 a is an elongated tail portion 78 a. Thelocking portion 76 a includes a portion 80 a, which defines a passagewayor passage portion 86 a. The passage portion 86 a extends between afirst opening 82 a and a second opening 84 a formed between suturebraids of the first suture tail 70 a. The first adjustable loop 56extends through the passage portion 86 a, thereby coupling the firstsuture tail 70 a to the suture strand 50. Similarly, the second suturetail 70 b can be arranged such that the suture strand 50 of the secondadjustable loop 58 extends through passageway 86 b defined by the secondsuture tail 70 b at the locking portion 76 b.

As further described herein, the construct 14 is configured such thatupon pulling the first end 52 of the suture strand 50, a portion of thesuture strand 50 within the internal passage portion 66 will be pulledout through the first sleeve end 62 thereof, thus closing the firstadjustable loop 56, and reducing the size thereof. Similarly, pullingthe second end 54 pulls a portion of the suture strand 50 out of theinternal passage portion 66 at the second sleeve end 64, in order toreduce the size of, and close, the second adjustable loop 58. As thefirst and second ends 52 and 54 are pulled, the first and secondadjustable loops 56 and 58 are tensioned, thus causing the internalpassage portion 66 to collapse onto portions of the suture strand 50extending therethrough, thereby restricting movement of the suturestrand 50 through the sleeve internal passage 66, and thus locking thefirst and second adjustable loops 56 and 58 to prevent them fromreopening. In this manner, the first and the second adjustable loops 56and 58 are self-locking.

Prior to the tissue fixation device 10 being implanted, the first andsecond adjustable loops 56 and 58 can be provided in a retracted orclosed position, such that the first and second adjustable loops 56 and58 are small, which can advantageously reduce any possibility oftangling of the first and second adjustable loops 56 and 58. In order toopen the first and second adjustable loops 56 and 58, the first suturetail 70 a can be pulled at the second end 74 a, thereby pulling aportion of the suture strand 50 out from within the internal passageportion 66 at the second sleeve end 64. The second adjustable loop 58can be opened by pulling the second suture tail 70 b, such as at thesecond end 74 b, in order to pull a portion of the suture strand 50 outfrom within the internal passage portion 66 at the first sleeve end 62.Because the first and the second adjustable loops 56 and 58 have not yetbeen tensioned, such as when closed against tissue 120 to secure thetissue 120 to bone 110 as described herein, and the anchor 12 has notyet collapsed as illustrated in FIG. 7 for example, the first and thesecond adjustable loops 56 and 58 can be opened in this manner.

With reference to FIG. 2 , the tissue fixation device 10 is illustratedimplanted in bone 110. The bone 110 includes a relatively soft innercancellous bone layer 112, and a relatively hard outer cortical bonelayer 114. An outer surface 116 of the bone 110 is at a side of thecortical bone layer 114 opposite to the cancellous bone layer 112.Formed within the bone 110 is a bone hole 118. The bone hole 118 isformed through the outer surface 116, through the outer cortical bonelayer 114, and into the cancellous bone layer 112. The bone hole 118 canbe formed in any suitable manner, such as with a suitable drill orimpactor, or any other suitable bone cutting device.

The tissue fixation device 10 is arranged such that the anchor 12 isseated in the bone hole 118. The anchor 12 protrudes slightly into thecancellous bone layer 112 proximate to the cortical bone layer 114 atthe first and second anchor ends 20 and 22 thereof. The first and thesecond end surfaces 30 and 32 abut the cortical bone layer 114 at a sidethereof opposite to the outer surface 116 and adjacent to the cancellousbone layer 112. As illustrated in FIG. 2 , the first and secondadjustable loops 56 and 58 are made smaller or closed, so as to reduceany possibility of tangling, as described above. After one or more ofthe tissue fixation devices 10 are implanted in bone, they may be usedto secure tissue 120 to bone 110, as will now be described.

With reference to FIG. 3 , two of the tissue fixation devices 10 areillustrated implanted in the bone 110 in the same manner as illustratedin FIG. 2 . The tissue fixation devices 10 can be used to secure tissue120 to the bone 110. The two tissue fixation devices 10 are illustratedas first tissue fixation device 10 a and second tissue fixation device10 b. Only the first tissue fixation device 10 a need be used to securetissue 120 to bone 110. To enhance fixation of the tissue 120 to bone110, however, additional tissue fixation devices 10 can be used, such asthe second tissue fixation device 10 b or yet additional tissue fixationdevices 10, as described herein.

The second tissue fixation device 10 b is substantially similar to, orthe same as, the first tissue fixation device 10 a. The second tissuefixation device 10 b includes first and second suture tails 70 c and 70d, which are similar to, or the same as, the first and second suturetails 70 a and 70 b of the first tissue fixation device 10 a. The firstand second adjustable loops of the second tissue fixation device 10 bare illustrated at reference numerals 56 b and 58 b respectively.

After the tissue fixation devices 10 a and 10 b are initially seated inthe bone hole 118 as illustrated in FIG. 2 , their suture tails 70 a, 70b, 70 c, and 70 d are pulled through the tissue 120, as illustrated inFIG. 3 . The tails 70 a, 70 b, 70 c, and 70 d and the loops 56 a, 58 a,56 b, and 58 b are then arranged as described below and illustrated inFIGS. 4-7 to apply pressure against the tissue 120 and secure the tissue120 against the outer bone surface 116.

FIGS. 4-7 illustrate arrangement of the first and second tails 70 a and70 b, and the first and second loops 56 a and 56 b, of tissue fixationdevice 10 (illustrated in FIG. 3 at reference number 10 a to distinguishthe second tissue fixation device 10 b) to retain the tissue 120 againstthe outer bone surface 116. The method of FIGS. 4-7 applies to both thefirst and second tissue fixation devices 10 a and 10 b of FIG. 3 .

After the tissue fixation device 10 has been seated in the bone hole 118as illustrated in FIG. 2 , the first and second suture tails 70 a and 70b are pulled through the tissue 120, thus pulling the first and secondadjustable loops 56 and 58 through the tissue 120 as well, as initiallyset forth above. The first and second suture tails 70 a and 70 b, andthe first and second adjustable loops 56 and 58 associated therewith,are pulled through spaced apart areas of the tissue 120, thus leaving aportion of the tissue 120 between the first and second adjustable loops56 and 58.

With reference to FIG. 4 , after the first and second adjustable loops56 and 58 are pulled through the tissue 120 using the first and secondsuture tails 70 a and 70 b, the first and second adjustable loops 56 and58 can be coupled together and cinched down against the tissue 120 inorder to secure the tissue against the outer surface 116 of the bone110. For example, the second end 74 a of the first suture tail 70 a canbe pulled through the second adjustable loop 58 in order to pull thefirst suture tail 70 a through the second adjustable loop 58, and pullthe first adjustable loop 56 such that a portion thereof extends throughthe second adjustable loop 58, as illustrated in FIG. 5 .

With reference to FIG. 6 , the second adjustable loop 58 is cinched downonto the first adjustable loop 56 by pulling on the second end 54. Asthe second end 54 is pulled, the second adjustable loop 58 will reducein size and pull the first adjustable loop 56 against the tissue 120,and affix the tissue 120 to the outer surface 116 of the bone 110. Withreference to FIG. 7 , after the size of the second adjustable loop 58 isreduced, the size of the first adjustable loop 56 is reduced by pullingthe first end 52 of the suture strand 50. As the first adjustable loop56 is reduced in size, the first suture tail 70 a will abut the secondsuture tail 70 b and/or the second adjustable loop 58. As the first end52 is pulled further, the first suture tail 70 a and/or the firstadjustable loop 56 will pull the second suture tail 70 b and the secondadjustable loop 58 further against the tissue 120, in order to furthersecure the tissue 120 to the outer surface 116 of the bone 110. As thefirst and second ends 52 and 54 are pulled as illustrated in FIGS. 6 and7 respectively, the first and second adjustable loops 56 and 58 aretensioned, thus causing the internal passage portion 66 to collapse ontoportions of the suture strand 50 extending therethrough, therebyrestricting movement of the suture strand 50 through the internalpassage portion 66, and thus locking the first and second adjustableloops 56 and 58 to prevent them from reopening. The anchor 12 will thendeform as illustrated in FIG. 7 to lock the anchor 12 in the bone hole118.

Although FIGS. 3-7 illustrate coupling together first and secondadjustable loops 56 and 58 from the same tissue fixation device 10,various other configurations and arrangements are contemplated. Forexample, and with reference to FIG. 8 , in applications where both thefirst tissue fixation device 10 a and the second tissue fixation device10 b are used, the first suture tail 70 a of the first tissue fixationdevice 10 a can be coupled to the second tissue fixation device 10 b.This can be done by inserting the first suture tail 70 a through thesecond adjustable loop 58 b of the second tissue fixation device 10 b,which will couple the first adjustable loop 56 a of the first tissuefixation device 10 a to the second adjustable loop 58 b of the secondtissue fixation device 10 b once the second adjustable loop 58 b iscinched down onto the first adjustable loop 56 a in the same mannerdescribed above. Similarly, the second adjustable loop 58 b of thesecond tissue fixation device 10 b can be coupled to the firstadjustable loop 56 a of the first tissue fixation device 10 a by closingthe second adjustable loop 58 a onto the first adjustable loop 56 b asdescribed above. Use of both the first and second tissue fixationdevices 10 a and 10 b to fix the tissue 120 to the bone 110advantageously retains a greater portion of the tissue 120 against thebone 110, thereby distributing load against the tissue 120 anddecreasing any possibility of the suture strands 50 cutting through thetissue 120.

With reference to FIG. 9 , a third tissue fixation device 10 c can beused to affix the tissue 120 to the bone 110. The third tissue fixationdevice 10 c can be similar to, or the same as, the first and secondtissue fixation devices 10 a and 10 b. The third tissue fixation device10 c can be implanted in the bone 110 spaced apart from the tissue 120,and beyond a distal end 122 thereof.

The third tissue fixation device 10 c can be coupled with the first andsecond tissue fixations device 10 a and 10 b in any suitable manner. Forexample, the first suture tail 70 a of the first tissue fixation device10 a can be inserted through a first adjustable loop 56 c of the thirdtissue fixation device 10 c in order to couple the first adjustableloops 56 a and 56 c together after the first adjustable loop 56 c iscinched down onto the first adjustable loop 56 a of the first tissuefixation device 10 a. The second adjustable loop 58 c of the thirdtissue fixation device 10 c can be coupled to the second adjustable loop58 b of the second tissue fixation device 10 b, such as by inserting thesecond suture tail 70 d through the second adjustable loop 58 c andclosing the second adjustable loop 58 c onto the second adjustable loop58 b. The first and second tissue fixation devices 10 a and 10 b can beconnected by coupling the second adjustable loop 58 a of the firsttissue fixation device 10 a with the first adjustable loop 56 b of thesecond tissue fixation device 10 b as described above. Thus, the suturetails 70 a-70 f are coupled to loops 56 a-56 c and 58 a-58 c ofneighboring tissue fixation devices 10 a-10 c in order to chain thetissue fixation devices 10 a-10 c together. Including the third tissuefixation device 10 c in the arrangement of FIG. 9 advantageously securesthe distal end 122 of the tissue 120 to the outer surface 116 of thebone 110.

With reference to FIGS. 10 and 11 , an additional soft or flexibleanchor 90 may be added to the tissue fixation device 10 in order toprovide additional fixation of the tissue 120. The anchor 90 may besimilar to the anchor 12, or any other suitable soft or flexible anchorthat is deformable in order to be retained in the bone hole 124. Theanchor 90 can be added to the tissue fixation device 10 in any suitablemanner, such as with a threader 130 illustrated in FIG. 10 . Thethreader 130 includes a loop portion 132 at a distal end of elongatedrods 134. The anchor 90 is initially seated on the elongated rods 134such that the elongated rods 134 extend through the anchor 90.

The anchor 90 can be attached to the first suture tail 70 a by firstpassing the tail portion 78 a thereof into the loop portion 132, andfolding the tail portion 78 a over the loop portion 132. The anchor 90is then slid over the tail portion 78 a that is folded over the loopportion 132, and onto the first suture tail 70 a. The first suture tail70 a and the first adjustable loop 56 coupled thereto are then pulledthrough the anchor 90 so that the anchor 90 is seated on the firstadjustable loop 56. The anchor 90 can be implanted in the bone 110 inbone hole 124 beyond the distal end 122 of the tissue 120, asillustrated in FIG. 11 . As the first end 52 of the suture strand 50 ispulled, the first adjustable loop 56 will shorten, thus drawing thefirst suture tail 70 a against the anchor 90, and deforming the anchor90 so that the anchor 90 will be retained in the bone 110. The firstadjustable loop 56 will also span and contact the distal end 122 of thetissue 120 in order to retain the distal end 122 to the bore 110. Thefirst end 72 a of the first suture tail 70 a will catch on an end of theanchor 90 and the first adjustable loop 56 will pull the secondadjustable loop 58, as well as the tissue 120, towards the anchor 90,thereby tensioning the tissue 120 in the anterior to posteriordirection, for example.

With reference to FIG. 12 , another tissue fixation device according tothe present teachings is illustrated at numeral 210. The tissue fixationdevice 210 generally includes a soft or flexible anchor 212 and aself-locking construct 214. The soft or flexible anchor 212 can be anysuitable anchor, such as the anchor 12 described above, or any suitablealternate configurations thereof, such as the alternate configurationsdescribed above. The anchor 212 generally includes a first end 220 and asecond end 222, which is opposite to the first end 220. The anchor 212defines a first opening 224 at the first end 220, and a second opening226 at the second end 222. An anchor internal passage 228 extendsthrough the anchor 212 between the first opening 224 and the secondopening 226.

The self-locking construct 214 can be any suitable self-lockingconstruct, such as a construct including a suture 250. Alternately, theconstruct 214 can be any of the alternate constructs described abovewith respect to the construct 14. The suture 250 generally includes afirst end 252 and a second end 254, which is opposite to the first end252. The construct 214 defines a first loop 256 and a second loop 258,which are formed as described below.

A first body portion 260 of the suture 250 is generally between thefirst loop 256 and the second loop 258, and defines a passageway 262extending between a first end 264 and a second end 266, through whichthe suture 250 extends to define the first loop 256. The first loop 256extends from the first body portion 260. The suture 250 further includesa second body portion 270 proximate to the second end 254. The secondbody portion 270 defines a passageway 272 extending between a firstopening 274 and a second opening 276 through which the suture 250extends to define the second loop 258. The second loop 258 extends fromthe second body portion 270. The anchor 212 is seated on the first loop256, such that portions of the suture 250 defining the first loop 256extend through the anchor internal passage 228.

The tissue fixation device 210 further includes a first tail 280 a and asecond tail 280 b. The first tail 280 a is coupled to the first loop256, and the second tail 280 b is coupled to the second loop 258. Thefirst and second tails 280 a and 280 b can be made of any suitablematerial, such as braided hollow-core suture. The first and second tails280 a and 280 b can also be made of the same material that the first andsecond suture tails 70 a and 70 b of FIG. 1 are made of.

The first tail 280 a is substantially similar to, or the same as, thesecond tail 280 b. Therefore, the description of the first tail 280 aalso applies to the second tail 280 b. Features in common between thefirst tail 280 a and the second tail 280 b are illustrated and describedusing like reference numbers, with the features of the first tail 280 aincluding the suffix “a” and the features of the second tail 280 bincluding the suffix “b.” To facilitate distinguishing between the firstand second tails 280 a and 280 b, such as by a surgeon in an operatingroom, the first and second tails 280 a and 280 b can include anysuitable distinguishing features. For example, the first tail 280 a canhave a different color, pattern, design, length or width as compared tothe second tail 280 b.

The first tail 280 a includes a first end 282 a and a second end 284 a,which is opposite to the first end 282 a. Proximate to the first end 282a is a locking member/portion 286 a. Extending from the lockingmember/portion 286 a to the second end 284 a is a first tail portion 288a. The first tail 280 a defines a passageway 290 a at the locking memberportion 286 a. The passageway 290 a extends between a first opening 292a and a second opening 294 a of the first tail 280 a. The first loop 256extends through the passageway 290 a. The first tail 280 a and thesecond tail 280 b can be used to adjust the sizes of the first and thesecond loops 256 and 258 respectively, as described herein with respectto FIGS. 22A-22C.

The first loop 256 can be made smaller by pulling the first end 252through the passageway 262, thereby pulling a portion of the suture 250proximate to the first end 252 through the passageway 262. The secondloop 258 can be made smaller by pulling the second end 284 b of thesecond tail 280 b away from the passageway 272 so as to slide the secondbody portion 270 towards the second tail 280 b. Although the second loop258 is illustrated as an adjustable loop, the second loop 258 can be arigid loop fixedly secure at the second body portion 270, for example,so as to restrict the second loop 258 from opening or closing.

The tissue fixation device 210 can be implanted in bone 110 in anysuitable manner, such as described above with respect to the tissuefixation device 10 in FIG. 2 . The tissue fixation device 210 can beused to secure tissue 120 to the bone 110 in any suitable manner, suchas described above with respect to the tissue fixation device 10. Forexample, the anchor 212 can be seated into the bone hole 118 and thenthe first and second tails 280 a and 280 b can be passed through thetissue 120. The first tail 280 a can be passed through the second loop258, so as to arrange the first loop 256 such that a portion thereofextends through the second loop 258. The first loop 256 can be madesmaller so as to press against and onto the tissue 120 by pulling thefirst end 252, which reduces the length of the first loop 256.

As the first end 252 is pulled, the locking member/portion 286 a engagesthe second loop 258, so as to prevent the first tail 280 a from passingback through the second loop 258. Furthermore, tension between theportion of the suture 250 extending through the passageway 262 and aninterior of the passageway 262 causes the passageway 262 to collapse onthe suture 250 and prevent the first loop 256 from reopening. If thesecond loop 258 is provided as a flexible loop, the second loop 258 maybe made smaller by pulling the second tail 280 b. Tension between theportion of the suture 250 extending through the passageway 272 and aninterior of the passageway 272 cause the passageway 272 to collapse ontothe suture 250 and prevent the second loop 258 from reopening.

Although FIG. 12 illustrates the tissue fixation device 210 with theanchor 212 on the first loop 256, the anchor 212 of the tissue fixationdevice 210 can be initially seated on the first tail 280 a, asillustrated in FIG. 13 , such that the first tail portion 288 a extendsthrough the anchor internal passage 228. With reference to FIGS. 14-18 ,use of the tissue fixation device 210 of FIG. 13 with the anchor 212initially seated on the first tail 280 a to secure tissue 120 to thebone 110 will now be described. In applications where the anchor 212 isinitially seated on the first loop 256, as illustrated in FIG. 12 , themethod of FIGS. 14-18 may also be used to secure tissue 120 to bone 110.

The anchor 212 is initially implanted in the bone hole 118, and thefirst tail 280 a is passed through the tissue 120. A cannula 310 isarranged such that it extends through a patient's outer skin layer tofacilitate introduction of the tissue fixation device 210 to an implantsite, and to facilitate manipulation of the tissue fixation device 210outside of the patient's body. By arranging the anchor 212 on the firsttail 280 a as opposed to on the first loop 256 as illustrated in FIG. 12, the construct 214 can remain outside of the joint space during much ofthe procedure to facilitate management of the fixation device 210, andparticularly management of the construct 214.

After the first tail 280 a is passed through the tissue 120 asillustrated in FIG. 14 , the second tail 280 b is passed through thecannula 310, through the tissue 120, and back through the cannula 310,as illustrated in FIG. 15 . With reference to FIG. 16 , the first tail280 a is then passed through the second loop 258. Passing the first tail280 a through the second loop 258 draws the construct 214 through thecannula 310 and into engagement with the tissue 120, as illustrated inFIG. 17 . More specifically, the first tail 280 a is pulled until itcompletely passes through the tissue 120 and pulls the first loop 256through the anchor 212 and up from the anchor 212 through the tissue120. Pulling the first tail 280 a also positions the second tail 280 bat the tissue 120 such that the locking member/portion 286 b abuts thetissue. To close the first loop 256 and secure the tissue 120 againstthe bone 110, the first end 252 of the suture 250 is pulled, asillustrated in FIG. 17 . Excess portions of the first and second tails280 a and 280 b can be removed after the first loop 256 has beencompletely zipped down, as illustrated in FIG. 18 for example. Thus,with the tissue fixation device 210, only a single suture strand need bepulled to close and tighten the construct 214 against the tissue 120.

A single tissue fixation device 210 can be used to secure the tissue 120to the bone 110, or multiple tissue fixation devices 210 can be used.For example, multiple tissue fixation devices 210 can be individuallyimplanted and not connected to each other, similar to the arrangementillustrated in FIG. 3 with respect to the tissue fixation device 10.Alternatively, multiple ones of the tissue fixation device 210 can belinked together, similar to the arrangement of FIGS. 3 and 8 withrespect to the tissue fixation device 10. Thus, the first loop 256 ofthe tissue fixation device 210 can be coupled to the second loop 258 ofa neighboring tissue fixation device 210 by inserting the first tail 280a through the second loop 258 of the neighboring tissue fixation device.Furthermore, the first or second tails 280 a or 280 b can be coupled toan anchor, which then may be implanted in bone, similar to that which isillustrated in FIG. 11 with respect to the tissue fixation device 10.

With additional reference to FIG. 19 , the tissue fixation device 210can include a second tail in the form of a braided strip 350. Thebraided strip 350 can be made of any suitable material, such as suture,or of any of the alternatives described above with respect to the suturestrands 50 and 250. The braided strip 350 generally includes a flatbraided portion 352 and a round braided portion 354, as viewed incross-section, extending from the flat braided portion 352.

The flat braided portion 352 defines a first opening 356 and a secondopening 358. As illustrated in FIG. 19 , the second loop 258 passesthrough the first and second openings 356 and 358 in order to secure thebraided strip to the second loop 258. However, the second loop 258 isoptional and thus need not be included. When the tissue fixation device210 does not include the second loop 258, the braided strip 350 can becoupled to the suture 250 without a loop, such as with a knot or anyother suitable coupling configuration. The braided strip 350 may also beunitary with the rest of the suture 250.

Instead of passing the first tail 280 a through the second loop 258, thefirst tail can be passed through the flat braided portion 352 of thebraided strip 350. As a result, when the first loop 256 is made smaller,as was described above in connection with FIG. 17 , the braided strip350 will extend across the tissue 120 in order to dissipate load appliedto the tissue 120 by the tissue fixation device 210. The round braidedportion 354 expands the distance that the braided strip 350 will extendacross the tissue 120, thereby further dissipating load.

FIG. 19 illustrates the braided strip 350 (without the round braidedportion 354) as included with the tissue fixation device 210 prior tobeing introduced to an implant site. However, the braided strip 350 maybe added to the fixation device 210 after the first loop 256 has beenpassed through the tissue, as illustrated at FIG. 20 . For example, thebraided strip 350 may be arranged at the second end 284 a of the firsttail 280 a and at the second end 284 b of the second tail 280 b. Thefirst and second ends 282 a and 284 b may be passed through the braidedstrip 350, and the braided strip 350 may be slid down and across each ofthe first and second tails 280 a and 280 b using a pusher device 380until the braided strip 350 passes over the first ends 282 a and 282 bof the first and second tails 280 a and 280 b respectively. After thefirst end 252 of the suture 250 is pulled to close the first loop 256,excess portions of the first and second tails 280 a and 280 b may beremoved, as illustrated in FIG. 21 .

With reference to FIGS. 22A-22C, when the tissue fixation device 210 isprovided with the second loop 258 as an adjustable loop, the second loop258 can be moved from an intermediate position illustrated in FIG. 22Ato a closed position illustrated in FIG. 22B by pulling a portion of thesuture 250 extending beyond the second body portion 270 in the directionof the first end 252 (direction A), and pulling the second end 284 b ofthe second tail 280 b in generally the opposite direction (direction B).To reopen the second loop 258, the second end 254 of the suture 250 ispulled in direction C and the second end 284 b of the second tail 280 bis pulled in direction D, as illustrated in FIG. 22C. Being able toselectively open and close the second loop 258 is advantageous for anumber of reasons. For example, if the second loop 258 is accidentallyclosed prematurely, the second loop 258 can easily be reopened, such asto permit passage of the first tail 280 a therethrough.

The foregoing description of the embodiments has been provided forpurposes of illustration and description. It is not intended to beexhaustive or to limit the disclosure. Individual elements or featuresof a particular embodiment are generally not limited to that particularembodiment, but, where applicable, are interchangeable and can be usedin a selected embodiment, even if not specifically shown or described.The same may also be varied in many ways. Such variations are not to beregarded as a departure from the disclosure, and all such modificationsare intended to be included within the scope of the disclosure.

What is claimed is:
 1. A method of tissue fixation, comprising: locatinga first bone anchor in a first bone hole with a first adjustable sutureconstruct extending down into the first bone hole and at least partiallythrough the first bone anchor to couple the first adjustable sutureconstruct to the first bone anchor, the first adjustable sutureconstruct including a first suture with a first free end that extendslongitudinally through a first longitudinal passage in the first sutureto form a first adjustable loop, the first adjustable suture constructfurther including a first flexible tail coupled to the first adjustableloop; the first flexible tail including a first tail end that extendsaway from the first adjustable loop; passing the first tail end at leastpartially through a second bone anchor outside the first bone hole toseat the second bone anchor on the first adjustable loop; and deliveringthe second bone anchor into a second bone hole after said passing. 2.The method of claim 1, wherein the second bone anchor comprises aflexible tubular anchor.
 3. The method of claim 2, wherein said passingincludes receiving the first tail end of the first flexible tail througha looped portion of a threading instrument that is extendinglongitudinally through at least a portion of the flexible tubular anchorand thereafter using the threading instrument to pull the first tail endat least partially through the flexible tubular anchor.
 4. The method ofclaim 1, wherein the first flexible tail comprises a hollow core suture,and wherein the first flexible tail being coupled to the firstadjustable loop includes suture of the first adjustable loop extendinglongitudinally through the hollow core suture.
 5. The method of claim 1further comprising: (i) pulling on the first free end of the firstsuture after said locating so as to decrease the size of the firstadjustable loop; and/or (ii) pulling on the first tail end after saidlocating so as to increase a size of the first adjustable loop.
 6. Themethod of claim 1, wherein, following said delivering, at least a firstsegment of the first adjustable loop extends down into the second bonehole.
 7. The method of claim 1, wherein, following said delivering, thefirst adjustable loop at least spans a distance from the first bone holeto the second bone hole.
 8. The method of claim 1, wherein theadjustable suture: construct includes a second adjustable loop.
 9. Themethod of claim 8, wherein said locating leaves at least a first portionof the second adjustable loop extending from the first bone anchor andup through a segment of soft tissue positioned over the first bone holeso as to position the first portion of the second adjustable loop atopthe segment of soft tissue.
 10. The method of claim 9 further comprisingpassing the first tail end through the first portion of the secondadjustable loop that is positioned atop the segment of soft tissue priorto passing the first tail end at least partially through the second honeanchor to seat the second bone anchor on the first adjustable loop. 11.A method of tissue fixation, comprising: locating a first bone anchor ina first bone hole with a first adjustable suture construct extendingdown into the first bone hole and at least partially through the firstbone anchor to couple the first adjustable suture construct to the firstbone anchor, the first adjustable suture construct including a firstsuture with a first free end and a second free end, the first free endextending longitudinally through a first longitudinal passage in thefirst suture to form a first adjustable loop and the second free endextending longitudinally through a second longitudinal passage in thefirst suture to form a second adjustable loop, the first adjustable loopand the second adjustable loop each having an adjustable size, whereinsaid locating leaves at least a first portion of the first adjustableloop and at least a first portion of the second adjustable loop outsidethe first bone hole; advancing the first portion of the first adjustableloop through the first portion of the second adjustable loop outside thefirst bone hole after said locating; passing, after said advancing, thefirst portion of the first adjustable loop at least partially through asecond bone anchor outside the first bone hole to seat the second boneanchor on the first adjustable loop; and delivering the second boneanchor into a second bone hole after said passing.
 12. The method ofclaim 11, wherein the second bone anchor comprises a flexible tubularanchor.
 13. The method of claim 12, wherein said passing includes usinga threading instrument that is extending longitudinally through at leasta portion of the flexible tubular anchor to pull the first portion ofthe first adjustable loop at least partially through the flexibletubular anchor.
 14. A method of tissue fixation, comprising: locating afirst bone anchor in a first bone hole with a first adjustable sutureconstruct extending down into the first bone hole and at least partiallythrough the first bone anchor to couple the first adjustable sutureconstruct to the first bone anchor, the first adjustable sutureconstruct including a first suture with a first free end that extendslongitudinally through a first longitudinal passage in the first sutureto form a first adjustable loop, the first adjustable loop having anadjustable size, wherein said locating leaves at least a first portionof the first adjustable loop outside the first bone hole; passing, aftersaid locating, the first portion of the first adjustable loop at leastpartially through a second bone anchor outside the first bone hole toseat the second bone anchor on the first adjustable loop; and deliveringthe second bone anchor into a second bone hole after said passing,wherein the second bone anchor comprises a flexible tubular anchor. 15.The method of claim 14 further comprising increasing the adjustable sizeof the first adjustable loop after said locating and then, after saidincreasing, decreasing the adjustable size of the first adjustable loop.16. The method of claim 15, wherein said increasing includes pulling ona first flexible tail that is coupled to the first adjustable loop. 17.The method of claim 16, wherein the first flexible tail comprises ahollow core suture, and wherein the first flexible tail being coupled tothe first adjustable loop includes suture of the first adjustable loopextending longitudinally through the hollow core suture.
 18. The methodof claim 14, wherein said passing includes using a threading instrumentthat is extending longitudinally through at least a portion of theflexible tubular anchor to pull the first portion of the firstadjustable loop at least partially through the flexible tubular anchor.19. The method of claim 14, wherein, following said delivering, thefirst portion of the first adjustable loop extends down into the secondbone hole.
 20. The method of claim 14, wherein, following saiddelivering, the first adjustable loop at least spans a distance from thefirst bone hole to the second bone hole.